North Bristol Referral form for Emergency Surgical Clinic



North Bristol GP Referral form for Abdominal pain/ Rectal Bleed Hot Clinic

Please fax this form to 01173406798 AND phone Surgical Admissions Unit on 01173406799 to book this patient into hot clinic

|Patient Name: |

|Date: |GP Name: |

|DOB: |GP Practice: |

|NHS / Hospital No: |GP Tel. No: |

|Patient Tel No: |GP Fax No: |

|Please tick one of the options below if an Ultrasound scan is required |Areas examined with Ultrasound |Prep |

| |All other requests should not be made | |

| |via this pathway. | |

|Lower abdominal pain - male |USS not required |[pic] |None |- |

|Obstructive Jaundice |Upper abdominal USS |[pic] |Liver, biliary tree, gallbladder, |Clear fluids only 4hours|

| | | |pancreas, spleen, abdominal aorta and |prior to scan |

| | | |kidneys | |

|RUQ/ Epigastric pain |Upper abdominal USS |[pic] | | |

|Lower abdominal pain - female |Lower abdominal USS |[pic] |Uterus, ovaries, urinary bladder and |Full bladder |

| | | |kidneys | |

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Please tick this box to confirm that the patient does not fall into any of the above categories [pic]

Please tick this box to confirm that the patient has been given the hot clinic leaflet [pic]

If the patient is of childbearing age, please tick to confirm that pregnancy been ruled out [pic]

The following conditions are NOT appropriate for hot clinic ultrasound and should be referred to radiology via the usual pathway if a scan is required:

• Wound collections / Abscesses (for review on surgical admissions unit)

• Hernia (can be seen in hot clinic but scan not possible)

• Abdominal wall conditions (can be seen in hot clinic but scan not possible)

• Testicular problems (discuss with Urologists)

• Bowel problems (ultrasound not an appropriate investigation but can be seen in clinic)

Patients that are NOT appropriate referrals to the GI Surgery Hot Clinic include

• Ischaemic / cellulitic limbs / abscesses

• Non GI / non abdominal problems

• Patients with chronic problems (should be referred to the relevant regular outpatient clinic)

• Patients too unwell to walk to radiology (should be admitted to hospital instead)

Clinical Examination:

Symptoms:

Working diagnosis:

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